During the course of carrying out a bed-wash, a health care
assistant briefly left an elderly and highly dependent resident
unattended, and she fell from her bed to the floor. On her return,
the health care assistant picked up the woman and placed her back
on her bed. The health care assistant did not, as required by rest
home policy, inform anyone of what had occurred or complete an
incident report.

Later that morning, after bruising appeared on the resident's
head, the nurse manager asked the health care assistant to explain
what had occurred. The health care assistant filled in an incident
report stating that the resident had bumped her head on a bedside
cabinet. On the basis of this information, a medical review was
initiated by the rest home. Later that day, a registered nurse
found skin tears and other bruising on the body of the resident,
which indicated to her that a more serious event had occurred. A
more thorough medical review was initiated.

Two days later, the health care assistant provided her employer
with a correct description of the resident falling from her bed,
and the assistant's actions in picking up the resident and moving
her unaided. The assistant had received training in lifting
procedures and knew she was required to complete an incident report
on an event such as a fall. She said she did not do so out of fear
that she would lose her job.

It was held that the health care assistant failed to report or
record the fall and, when asked to explain the appearance of
bruising, she failed to report accurately what had occurred. This
resulted in other providers being unaware of the full extent of the
resident's injuries, and compromised the care she received.

When the health care assistant did complete a full incident
report on the fall she acknowledged that, contrary to procedure,
she had twice lifted the elderly resident on her own, further
placing the resident at risk of increased injury.

The health care assistant was held to have breached Rights 4(1),
4(2) and 4(5). The fact that she had failed to promptly and
accurately report the fall and attempted to cover up what happened
was viewed with great concern. The health care assistant was
referred to the Director of Proceedings, who subsequently decided
not to issue proceedings.

The rest home was found not to have breached the Code because it
had provided the health care assistant with appropriate care
instructions and support. Another caregiver was available to assist
with lifting, and appropriate steps were taken to manage the
resident's injuries.

The nursing bureau that employed the health care assistant was
not found to be liable for her breach of the Code. It had provided
appropriate induction training to ensure its caregivers
familiarised themselves with and followed client policies and
procedures.